Priorytetyzacja i delegowanie w stylu NCLEX: zestaw na powtórkę

A patient has heart failure. Which instruction about daily weights is best to give the nursing assistant?

1. A“Weigh him after lunch, fully dressed, with his shoes on.”
2. B“Weigh him at any time today, on whichever scale is free.”
3. C“Weigh him each morning before breakfast, on the same scale, and tell me the result.”
4. D“Only weigh him if his ankles look more swollen than they did yesterday afternoon.”

A patient with suspected sepsis has four prescribed orders. Which should usually be done first?

1. AArrange a chest X-ray for later today
2. BGive the IV antibiotic
3. CTake blood cultures
4. DRepeat the lactate in six hours

A patient is on suicide precautions. Which room safety measure is appropriate?

1. AKeep the door closed at all times so the patient has privacy
2. BRemove items that could be used for self-harm, such as belts and cords
3. CLet the patient keep a personal razor for shaving, as long as staff are told
4. DAllow glass bottles if the patient seems calm

Pielęgniarka zauważa, że pompa infuzyjna pacjenta jest ustawiona na szybkość dziesięciokrotnie wyższą niż w zleceniu. Pacjent wydaje się czuć dobrze. Jakie jest pierwsze działanie?

1. APozostawić szybkość i udokumentować ustalenie w dokumentacji
2. BPoczekać, czy wystąpią jakieś działania niepożądane
3. CZapytać pacjenta, czy czuje się inaczej, i kontynuować
4. DZatrzymać lub skorygować wlew, a następnie ocenić pacjenta

A week after a splenectomy, a patient's platelet count is 650 × 10³/µL. What is the best interpretation?

1. AA sign of iron overload from the surgery and transfusion
2. BA laboratory error, because platelets fall after splenectomy
3. CAn expected rise after splenectomy that increases clot risk
4. DA sign of new leukemia that needs immediate chemotherapy

A 68-year-old man has fatigue, a hemoglobin of 9,8 g/dL (98 g/L), an MCV of 72 fL and a low ferritin. He eats a normal diet. What is the most important next step?

1. ARepeat the blood count in one year
2. BGive iron and do no further tests at all
3. CLook for a source of blood loss in the gut
4. DStart vitamin B₁₂ injections

Why are patients with atrial fibrillation often given anticoagulants?

1. ATo reduce the risk of stroke from clots in the atria
2. BTo slow the heart rate directly and prevent palpitations
3. CTo lower the blood pressure
4. DTo convert the rhythm back to normal

A patient faints during cannulation, with a slow pulse and pallor, and recovers quickly when laid flat. There is no rash, wheeze or swelling. What is most likely?

1. AA hypoglycaemic coma
2. BAnaphylaxis
3. CVasovagal syncope
4. DA stroke

Which ECG finding is typical of atrial flutter?

1. AA chaotic baseline with no clear P waves and irregular QRS
2. BRegular sawtooth flutter waves between QRS complexes
3. CP waves with no relationship to the QRS complexes
4. DWide, bizarre QRS complexes at 180/min

Przewód drenu klatki piersiowej pacjenta odłączył się od zestawu drenażowego. Co powinna zrobić pielęgniarka w pierwszej kolejności?

1. AUsunąć dren z klatki piersiowej i zakryć miejsce
2. BPonownie go połączyć lub zanurzyć koniec drenu w jałowej wodzie, a następnie ocenić pacjenta
3. CPozostawić otwarty do czasu przybycia lekarza na ocenę
4. DZacisnąć dren na kilka godzin i ponownie sprawdzić pacjenta później

Why can a patient with an insulin pump develop DKA within hours if the pump stops working?

1. AThe pump gives long-acting insulin, which builds up and stops working all at once
2. BThe pump gives only rapid-acting insulin, so there is no long-acting reserve
3. CThe body becomes allergic to insulin when the pump stops
4. DThe battery in the pump releases chemicals into the blood

Which patient on a stroke unit is most at risk of falling?

1. AA patient with a left-hemisphere stroke who has expressive aphasia and waits for help
2. BA patient with mild dysarthria who walks steadily with a frame
3. CA patient with a TIA whose symptoms resolved completely yesterday
4. DA patient with a right-hemisphere stroke who is impulsive and denies having weakness

Which change suggests that a burn wound is becoming infected?

1. AThe wound becoming pink and a little smaller at each dressing change
2. BLess exudate on each dressing change
3. CA partial-thickness burn becoming deeper, with new discolouration
4. DDry, healing skin with mild itching

In week 5 of radiotherapy, the skin in the treatment field is broken, moist and painful. What should the nurse do?

1. AApply adhesive tape directly over the area to protect it from clothing
2. BScrub the area with soap to prevent infection
3. CUse a heat pad to speed healing
4. DReport it, keep it clean and use a non-adherent dressing